Therapy

ABSTRACT

The present invention provides an oligonucleotide comprising the sequence 5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2) for use in the treatment of inflammatory bowel disease in a human subject, wherein individual doses of from 100 mg to 350 mg of said oligonucleotide are administered to the subject on at least four separate occasions, wherein the separate occasions are each a week apart.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is the U.S. National Phase Application under 35 U.S.C.§ 371 of International Application No. PCT/EP2018/062140, filed on May9, 2018, designating the U.S. and published in English as WO 2018/206722A1 on Nov. 15, 2018, which claims the benefit of priority to GB PatentApplication No. 1707503.7, filed on May 10, 2017. The disclosures ofthese related applications are herein expressly incorporated byreference in their entireties, including any drawings.

REFERENCE TO SEQUENCE LISTING

The present application is being filed along with a Sequence Listing inelectronic format. The Sequence Listing is provided as a file entitled“N408171WOSequenceListingMay2018_ST25”, created Nov. 8, 2019, which isapproximately 4 KB in size, and updated by a Replacement ElectronicSequence Listing file entitled“Amended_sequence_listing_N408171US_HCB_EGH_ST25”, created on Apr. 2,2020, which is 4 KB in size. The information in the electronic format ofthe Sequence Listings is incorporated herein by reference in itsentirety.

FIELD OF THE INVENTION

The present invention relates to new therapies for treating inflammatorybowel diseases, for instance active ulcerative colitis (UC), wherein anoligonucleotide, especially cobitolimod, is administered according to anoptimised dosage regime.

BACKGROUND OF THE INVENTION

Ulcerative colitis (UC) is a disease characterized by chronicinflammation of the rectal and colonic mucosa, affecting the innermostlining in the first stage. The disease is recurrent, with both activeand inactive stages that differ in pathology, symptoms and treatment.The underlying cause of UC is not understood, nor is it known whattriggers the disease to recur between its inactive and active forms(Irvine, E. J. (2008) Inflamm Bowel Dis 14(4): 554-565). Symptoms ofactive UC include progressive loose stools with blood and increasedfrequency of bowel movements. Active mucosal inflammation is diagnosedby endoscopy.

The stools contain pus, mucous and blood and are often associated withabdominal cramping with urgency to evacuate (tenesmi). Diarrhoea mayhave an insidious onset or, more rarely, start quite suddenly. In severecases the symptoms may include fever and general malaise. In severestages, deep inflammation of the bowel wall may develop with abdominaltenderness, tachycardia, fever and risk of bowel perforation.Furthermore, patients with UC may suffer extra intestinal manifestationssuch as arthralgia and arthritis, erythema nodosum, pyoderma gangrenosumand inflammation in the eyes. In the case of remission or inactive UC,patients are usually free of bowel symptoms.

The extent of inflamed and damaged mucosa differs among patients withUC. UC that affects only the rectum is termed ulcerative proctitis. Thecondition is referred to as distal or left sided colitis wheninflammatory changes are present in the left side of the colon up to thesplenic flexure. In extensive UC the transverse colon is also affected,and pancolitis designates a disease involving the entire colon.

Active mucosal inflammation is diagnosed by endoscopy and ischaracterized by a loss of vascular patterning, oedema, petechia,spontaneous bleeding and fibrinous exudates. The endoscopic picture isthat of continuous inflammation, starting in the rectum and extendingproximally to a variable extent into the colon. Biopsies obtained atendoscopy and subjected to histological examination help to diagnose thecondition. Infectious causes, including Clostridium difficile,camphylobacter, Salmonella and Shigella, may mimic UC and can beexcluded by stool cultures.

The medical management of UC is divided into treatment of active diseaseand maintenance of remission.

The treatment of patients with active UC aims to reduce inflammation andpromote colon healing and mucosal recovery. In milder cases the diseasemay be controlled with conventional drugs including sulphasalazine,5-aminosalicylic acid (5-ASA) (Sutherland, L., F. Martin, S. Greer, M.Robinson, N. Greenberger, F. Saibil, T. Martin, J. Sparr, E. Prokipchukand L. Borgn (1987) Gastroenterology 92: 1894-1898) andglucocorticosteroids (GCS) (Domenech, E., M. Manosa and E. Cabre (2014).Dig Dis 32(4): 320-327).

GCS are generally used to treat disease flare-ups and are notrecommended for maintenance of remission since there are significantside effects in long-term use, and the possible development of steroiddependent disease. Glucocorticoid drugs act non-selectively, so in thelong run they may impair many healthy anabolic processes. As a result,maintenance treatment with systemic GCS is not advised (Prantera, C. andS. Marconi (2013) Therap Adv Gastroenterol 6(2): 137-156).

For patients who become refractory to GCS and suffer from severe ormoderately severe attacks of UC, the addition of immunomodulatory agentssuch as cyclosporine, 6-mercaptopurine and azathioprine may be used.However, immunomodulators are slow-acting and the induction of remissionin these patients is often temporary (Khan, K. J., M. C. Dubinsky, A. C.Ford, T. A. Ullman, N. J. Talley and P. Moayyedi (2011) Am JGastroenterol 106(4): 630-642).

Further treatment options for UC include biologic agents (Fausel, R. andA. Afzali (2015) Ther Clin Risk Manag 11: 63-73). The three TNF-αinhibitors currently approved for the treatment of moderate to severe UCare infliximab, adalimumab, and golimumab. All three carry potentialrisks associated with their use, and should be avoided in certainpatients, e.g. those with uncontrolled infections, advanced heartfailure, neurologic conditions and in patients with a history ofmalignancy, due to a potential risk of accelerating the growth of atumour. Other potential adverse effects of TNF-α inhibitor therapyinclude neutropenia, hepatotoxicity, serum sickness, leukocytoclasticvasculitis, rash including psoriasiform rash, induction of autoimmunity,and injection or infusion site reactions, including anaphylaxis,convulsions, and hypotension.

All three TNF-α inhibitor agents and their related biosimilar/derivativecounterparts may be used to induce and maintain clinical response andremission in patients with UC. Combination therapy with azathioprine isalso used for inducing remission.

However, more than 50% of patients receiving TNF-α inhibitor agents failto respond to induction dosing, or lose response to the TNF-α inhibitoragents over time (Fausel, R. and A. Afzali (2015) Ther Clin Risk Manag11: 63-73).

Vedolizumab, a α4β7 integrin inhibitor, was recently approved for thetreatment of UC. In the GEMINI 1 trial, vedolizumab was found to be moreeffective than placebo for inducing and maintaining clinical response,clinical remission, and mucosal healing (Feagan, B. G., P. Rutgeerts, B.E. Sands, S. Hanauer, J. F. Colombel, W. J. Sandborn, G. Van Assche, J.Axler, H. J. Kim, S. Danese, I. Fox, C. Milch, S. Sankoh, T. Wyant, J.Xu, A. Parikh and G. S. Group (2013). “Vedolizumab as induction andmaintenance therapy for ulcerative colitis.” N Engl J Med 369(8):699-710.).

Ulcerative colitis patients, who are chronically active and refractoryto known treatments pose a serious medical challenge and often the onlyremaining course of action is colectomy. A total colectomy is apotentially curative option in severe UC, but is a life-changingoperation that entails risks as complications, such as pouch failure,pouchitis, pelvic sepsis, infertility in women, and nocturnal faecalsoiling, may follow. Therefore, surgery is usually reserved for patientswith severe refractory disease, surgical or other emergencies, orpatients with colorectal dysplasia or cancer.

An emergent third line treatment for UC is cobitolimod(Kappaproct/DIMS0150), a modified single strand deoxyribonucleic acid(DNA)-based synthetic oligonucleotide of 19 bases in length. Cobitolimodhas the sequence 5′-G*G*A*ACAGTTCGTCCAT*G*G*C-3′ (SEQ ID NO:1), whereinthe CG dinucleotide is unmethylated.

Cobitolimod functions as an immunomodulatory agent by targeting theToll-like receptor 9 (TLR9) present in immune cells. These immune cells(i.e., B-cells and plasmacytoid dendritic cell (pDCs) reside in highabundance in mucosal surfaces, such as colonic and nasal mucosa. Theimmune system is the key mediator of the changes of UC. The mucosa ofthe colon and rectum of patients with UC is chronically inflamed andcontains active immune cells. Cobitolimod may be topically administeredin the region of inflammation, which places the drug in close contactwith a high number of intended target cells, ensuring that the drug willreach an area rich in TLR9 expressing cells. The activation of thesecells by cobitolimod induces various cytokines, such as type Iinterferons and interleukin 10 (IL-10) which are classicalanti-inflammatory cytokines and are believed to be important factors forthe clinical effect of cobitolimod.

A range of non-clinical safety studies have been conducted withcobitolimod, as well as four clinical trials. The majority of the trialshave involved administration of a relatively low (30 mg) dose ofcobitolimod. Overall, data on cobitolimod support a positivebenefit-risk assessment for patients with chronic active UC. Cobitolimodis safe and well tolerated and has been shown to be effective to induceclinical response and remission in patients with chronic active UC, aswell as symptomatic and endoscopic remission in patients with treatmentrefractory, moderate to severe chronic active UC.

There now exists a need for improved dosage regimes for cobitolimod thatmaximise its efficacy/safety profile for clinical use.

SUMMARY OF THE INVENTION

It has now surprisingly been found that, for treatment of inflammatorybowel diseases such as UC, administration of cobitolimod at a dosage offrom 100 mg to 350 mg, preferably 100 mg to 150 mg, more preferablyaround 125 mg, on at least four, preferably four, separate occasionseach a week apart is optimal, for instance to induce remission. Theincrease in efficacy of the drug at 125 mg and 250 mg is more than wouldhave been expected from the previous clinical studies carried out atmuch lower doses.

The present invention therefore provides an oligonucleotide comprisingthe sequence 5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2) for use in thetreatment of inflammatory bowel disease in a human subject, whereinindividual doses of from 100 mg to 350 mg of said oligonucleotide areadministered to the subject on at least four separate occasions, whereinthe separate occasions are each a week apart.

The present invention also provides a pharmaceutical compositioncomprising an oligonucleotide as defined herein, together with one ormore pharmaceutically acceptable carriers, for use in the treatment ofinflammatory bowel disease as defined herein in a human subject asdefined herein, wherein individual administrations of said compositionare administered to the subject on at least four separate occasions,wherein the separate occasions are each a week apart, and wherein eachadministration of the composition delivers an amount of theoligonucleotide as defined herein.

The present invention also provides a method of treating inflammatorybowel disease as defined herein, in a human subject as defined herein,comprising administering to said subject an oligonucleotide as definedherein or a composition as defined herein, wherein individualadministrations of said oligonucleotide or composition are administeredto the patient on at least four separate occasions, wherein the separateoccasions are each a week apart, and wherein each administration of theoligonucleotide or composition delivers an amount of the oligonucleotideas defined herein.

In preferred embodiments, the oligonucleotide has the sequence5′-G*G*A*ACAGTTCGTCCAT*G*G*C-3′ (SEQ ID NO:1), wherein the CGdinucleotide is unmethylated. Thus, in preferred embodiments, theoligonucleotide is cobitolimod.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows the results for weight loss in mice in a DSS-inducedcolitis mouse model over 10 days.

FIG. 2 shows the results for disease activity index (DAI) in aDSS-induced colitis mouse model over 10 days.

FIG. 3 shows the results for endoscopic colitis grading in a DSS-inducedcolitis mouse model over 10 days.

FIG. 4 shows flow cytometry analysis showing percentage of IL17⁺,RORγT⁺, and IL17⁺ROR γT⁺ cells in CD4⁺ T cell subset of the Laminapropria mononuclear cells (LPMCs) isolated from mouse colon specimens ina DSS induced colitis mouse model at day 10.

FIG. 5 shows flow cytometry analysis of the Myeloid derived suppressorcell (MDSC CD11⁺Gr1⁺) population isolated from the mouse colon specimensin a DSS induced colitis mouse model at day 10.

DETAILED DESCRIPTION OF THE INVENTION

All patents, patent applications, and publications cited herein arehereby incorporated by reference in their entirety.

As used herein, the term “subject” refers to a human subject/patient.The terms “subject” and “patient” are used interchangeably herein.

As used herein, the term inflammatory bowel disease (IBD) refers to agroup of inflammatory conditions of the colon and the gastrointestinaltract. The major types of IBD are ulcerative colitis (UC) and Crohn'sdisease. The main difference between UC and Crohn's disease is thelocation and nature of the inflammatory changes. Crohn's disease canaffect any part of the gastrointestinal tract, from mouth to anus, whileUC is restricted to the colon and the rectum. In some cases, adefinitive diagnosis of either Crohn's disease or UC cannot be made dueto idiosyncrasies in the presentation. In these cases a diagnosis ofindeterminate colitis may be made. Other forms of IBD include, but arenot limited to, collagenous colitis, lymphocytic colitis, ischaemiccolitis, diversion colitis, Behçet's disease and indeterminate colitis.

Typically, the inflammatory bowel disease is ulcerative colitis (UC).

The disease ulcerative colitis (UC) is well known to one skilled in theart. Ulcerative colitis treated in accordance with the present inventionmay involve treatment of ulcerative proctitis, distal or left sidedcolitis, extensive colitis, pancolitis and pouchitis.

Patients with UC typically present with a spectrum of disease severityranging from remission to severely active. Clinical assessment can beused to classify UC patients into 4 disease activity subgroups asdefined in D'Haens, Gastroenterology 2007; 132: 763-786, the entirety ofwhich is incorporated herein by reference: (1) remission (≤2 or 3stools/day, without the presence of blood and/or pus in the stools, withno systemic symptoms); (2) mildly active disease (3 or 4 stools/dayand/or presence of blood and/or pus in the stools less than daily, withno systemic symptoms of fever or weight loss); (3) moderately activedisease (>4 stools/day and/or daily presence of blood and/or pus) withminimal systemic symptoms; and (4) severely active disease (>6 bloodystools/day, and evidence of toxicity, as demonstrated by fever,tachycardia, anemia, or an erythrocyte sedimentation rate ESR).

Typically, the patient is suffering from moderate to severe UC.Preferably, the patient is suffering from moderate to severe UC asdefined above.

As used herein, the words “treatment” and “treating” are to beunderstood as embracing treatment and/or amelioration and/or preventionof or reduction in aggravation/worsening of symptoms of a disease orcondition as well as treatment of the cause of the disease or condition,and may include reversing, reducing, or arresting the symptoms, clinicalsigns, and underlying pathology of a condition in a manner to improve orstabilise a subject's condition.

In particular in the context of ulcerative colitis, “treating” typicallyrefers to inducing response or remission in a patient having activeulcerative colitis. Thus, typically, the oligonucleotide is for inducingresponse or remission of active ulcerative colitis in a patient.Inducing response means improving the condition of a patient by e.g.reducing and/or arresting the symptoms and clinical signs of the activedisease. Inducing remission means transitioning a patient from a statewhere they are considered to be in an active stage of the disease to astate where they are considered to be in remission.

Induction of response or remission in UC patients is typically assessedby one or more of endoscopy, histology, patient recorded outcomes andquality of life outcomes. Thus, reference to induction of response orremission includes induction of one or more of endoscopic remission,endoscopic response, histological remission, histological response,response or remission as determined by physician or by patient recordedoutcomes, and response or remission as determined by quality of life.This can typically be assessed by reference to one or more standardindices.

Typically, ulcerative colitis is chronic active ulcerative colitis.

As used herein, the term “chronic active ulcerative colitis” refers topatients with ulcerative colitis that is both active and chronic. Activeulcerative colitis is typically as defined herein, i.e. the patient isnot in remission. Chronic ulcerative colitis refers to a diseasecharacterized by a chronic inflammation of the rectal and colonicmucosa.

Preferably, reference herein to “treating” refers to inducing responseor remission in a patient having chronic active ulcerative colitis.Thus, typically, the oligonucleotide is for inducing response orremission of chronic active ulcerative colitis in a patient.

Induction of response or remission in UC patients may be determined inaccordance with one or more standard disease indices. Typical diseaseindices include but not limited to the ones mentioned below; (i) diseaseactivity determined by clinical and biochemical disease activity, (ii)disease activity determined by endoscopic disease activity, (iii)disease activity determined by composite clinical and endoscopic diseaseactivity indices, (iv) quality of life, (v) histologic disease activity.These indices are discussed in D'Haens (ibid).

Indices based on disease activity determined by clinical and biochemicaldisease activity include the Truelove and Witts Severity Index;Powell-Tuck (St. Mark's) Index; Clinical Activity (Rachmilewitz) Index;Activity (Seo) Index; Physician Global Assessment; Lichtiger (ModifiedTruelove and Witts Severity) Index; Investigators Global Evaluation;Simple Clinical Colitis Activity Index; Improvement Based on IndividualSymptom Scores; Ulcerative Colitis Clinical Score; and Patient-definedremission. These indices are discussed in D'Haens (ibid).

Indices based on disease activity determined by endoscopic diseaseactivity include the Truelove and Witts Sigmoidoscopic Assessment; Baronscore; Powell-Tuck Sigmoidoscopic Assessment; Endoscopic (RachmilewitzEndoscopic) Index; Sigmoidoscopic Index; Sigmoidoscopic InflammationGrade Score; Mayo Score Flexible Proctosigmoidoscopy Assessment;Sutherland Mucosal Appearance Assessment; and Modified Baron Score.These indices are discussed in D'Haens (ibid).

Indices based on disease activity determined by composite clinical andendoscopic disease activity indices include the Mayo Score (Mayo ClinicScore/Disease Activity Index); Modified Mayo Score and Sutherland Index(Disease Activity Index/UC Disease Activity Index). Mayo Score andSutherland Index are discussed in D'Haens (ibid).

Indices based on quality of life include the Rating Form of IBD PatientConcerns; and the Inflammatory Bowel Disease Questionnaire (IBDQ). Theseindices are discussed in D'Haens (ibid).

Indices based on histologic disease activity include those discussed inD'Haens (ibid) such as Geboes Index and Riley Index and further indicessuch as Nancy Index and Robarts Index.

Preferred indices for assessing UC patients include the ClinicalActivity (Rachmilewitz) Index, Mayo Score and Modified Mayo Score.

The Clinical Activity (Rachmilewitz) Index is an index taking intoaccount 7 variables: number of stools, blood in stools, investigator'sglobal assessment of symptomatic state, abdominal pain or cramps,temperature due to colitis, extraintestinal manifestations, andlaboratory findings. This is discussed further in D'Haens (ibid) andRachmilewitz D., BMJ 1989; 298: 82-86, the entirety of which isincorporated herein by reference. Determination of the Clinical Activity(Rachmilewitz) Index produces a score for a patient ranging from 0 to 29points (higher scores meaning more severe disease).

Clinical remission may be considered as a Clinical Activity(Rachmilewitz) Index score≤4 points. Response as determined by theClinical Activity (Rachmilewitz) Index means the patient has a lowerscore after treatment than before treatment.

The Mayo Score is an index taking into account 4 items: stool frequency,rectal bleeding, findings of lower GI endoscopy, and Physician's GlobalAssessment (PGA). This is discussed further in D'Haens (ibid) andSchroeder K W et al, N Engl J Med 1987; 317: 1625-1629, the entirety ofwhich is incorporated herein by reference. Determination of the MayoScore produces a score ranging from 0 to 12 points (higher scoresmeaning more severe disease). In addition to the four specific items, apatient's functional assessment is also measured that is not meant to beincluded in the 12-point index calculation but should be used as ameasure of general well-being when determining the PGA score.

Mayo scoring for each of the 4 items is determined as set out in theTable below.

Physician's Stool Rectal global Colonoscopy/sigmoidoscopy Scorefrequency^(b) Bleeding^(c) assessment^(d) finding 0 Normal No bloodNormal or no Normal or inactive disease number of seen disease stoolsfor this patient 1 1 to 2 stools Streaks of Mild disease Mild disease(erythema, more than blood with decreased vascular pattern, normal stoolless mild friability) than half of the time 2 3 to 4 stools ObviousModerate Moderate disease (marked more than blood with disease erythema,lack of vascular normal stool most of pattern, friability, erosions) thetime 3 5 or more Blood alone Severe Severe disease (spontaneous stoolsmore passed disease bleeding, ulceration) than normal ^(b)Each patientserves as his or her own control to establish the degree of abnormalityof the stool frequency. ^(c)The daily bleeding score represents the mostsevere day of bleeding ^(d)The physician's global assessmentacknowledges the 3 other criteria, the patient's daily record ofabdominal discomfort and general sense of well-being, and otherobservations, such as physical findings and the patient's performancestatus.

Remission according to the Mayo Score may be defined as completeresolution of (1) stool frequency (normal stool frequency), (2) rectalbleeding (no rectal bleeding), (3) patient's functional assessment score(generally well), (4) endoscopy findings (normal), and a PGA score of 0.Response as determined by Mayo Score typically requires improvement (aminimum 1-point decrease from baseline) in the PGA score and improvementin at least one other clinical assessment (stool frequency, rectalbleeding, patient's functional assessment, endoscopy findings) and noworsening in any other clinical assessment.

Alternatively, clinical remission may be defined as a Mayo Score of 0and clinical improvement (response) as a decrease from baseline in theMayo Score≥3 points.

Alternatively, clinical remission may be defined as a Mayo Score of 0and clinical improvement (response) as a decrease from baseline in theMayo Score≥3 points (or a decrease of ≥2 points if the baseline MayoScore was ≤3 points).

Alternatively, remission as determined by Mayo Score may be defined asrequiring subscores of 0 for both sigmoidoscopy and rectal bleeding anda score of 0 or 1 for stool frequency and PGA subscores. Response may bedefined as a decrease from baseline in the Mayo Score≥3 points; clinicalresponse may be defined as a decrease from baseline in the Mayo Score(without the endoscopy subscore, also known as a Partial Mayo Score)≥2points, and endoscopic response may be defined as a decrease frombaseline in the endoscopic subscore≥1 point.

Alternatively, clinical remission may be defined as a total Mayo scoreof ≤2 points with no individual subscore>1 point, clinical response maybe defined as a decrease from baseline in the total Mayo score≥3 pointsand ≥30% and a decrease in the rectal bleeding subscore≥1 point or anabsolute rectal bleeding subscore of 0 or 1, and mucosal healing may bedefined as an absolute endoscopy subscore of 0 or 1.

In one embodiment, patients having active ulcerative colitis have a MayoScore>2. Patients who are in a remission phase of ulcerative colitistypically have a Mayo Score≤2.

Modified Mayo Score is related to the Mayo Score, which is definedabove. Modified Mayo Score differs from Mayo Score in that theColonoscopy/sigmoidoscopy scoring takes less account of friability.Thus, the scoring table for the Modified Mayo Score is as set out below.

Physician's Stool Rectal global Colonoscopy/sigmoidoscopy Scorefrequency^(b) Bleeding^(c) assessment^(d) finding 0 Normal No bloodNormal or no Normal or inactive disease number of seen disease stoolsfor this patient 1 1 to 2 stools Streaks of Mild disease Mild disease(erythema, more than blood with decreased vascular pattern) normal stoolless than half of the time 2 3 to 4 stools Obvious Moderate Moderatedisease (marked more than blood with disease erythema, lack of vascularnormal stool most of pattern, friability, erosions) the time 3 5 or moreBlood alone Severe Severe disease (spontaneous stools more passeddisease bleeding, ulceration) than normal ^(b)Each patient serves as hisor her own control to establish the degree of abnormality of the stoolfrequency. ^(c)The daily bleeding score represents the most severe dayof bleeding ^(d)The physician's global assessment acknowledges the 3other criteria, the patient's daily record of abdominal discomfort andgeneral sense of well-being, and other observations, such as physicalfindings and the patient's performance status.

Remission and response values for the Modified Mayo Score are as set outabove for the Mayo Score. Modified Mayo Score is typically assessed inaccordance with the FDA's draft guidance document “Ulcerative Colitis:Clinical Trial Endpoints Guidance for Industry” found atfda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM515143.pdf

Alternatively, Modified Mayo Score may differ from Mayo Score in thatthe Colonoscopy/sigmoidoscopy scoring takes less account of friabilityand also in that Physician's Global Assessment is not determinative.Thus, the scoring table for the Modified Mayo Score may also be asfollows.

Stool Rectal Colonoscopy/sigmoidoscopy Score frequency^(b) Bleeding^(c)finding 0 Normal No blood Normal or inactive disease number of seenstools for this patient 1 1 to 2 stools Streaks of Mild disease(erythema, more than blood with decreased vascular pattern) normal stoolless than half the time 2 3 to 4 stools Obvious Moderate disease (markedmore than blood with erythema, lack of vascular normal stool most ofpattern, friability, erosions) the time 3 5 or more Blood alone Severedisease (spontaneous stools more passed bleeding, ulceration) thannormal ^(b)Each patient serves as his or her own control to establishthe degree of abnormality of the stool frequency. ^(c)The daily bleedingscore represents the most severe day of bleeding

Remission and response values for this alternative Modified Mayo Scoreare typically as set out above for the Mayo Score. Alternatively,remission may be defined in accordance with this alternative ModifiedMayo Score by sub-scores of i) rectal bleeding of 0, ii) stool frequencyof 0 or 1 (with at least one point decrease from Baseline, Week 0), andiii) endoscopy score of 0 or 1 (excluding friability).

Induction of remission of UC may be in accordance with the criteria setout in S. P. L. Travis, Aliment Pharmacol Ther 2011; 34: 113-124, theentirety of which is incorporated herein by reference, i.e. completecessation of rectal bleeding, urgency and increased stool frequency,preferably confirmed by endoscopic mucosal healing.

Alternatively, induction of response or remission may be in accordancewith the criteria set out in E. F. Stange, Journal of Crohn's andColitis (2008) 2, 1-23; S. P. L. Travis, Journal of Crohn's and Colitis(2008) 2, 24-62; K Geboes, Gut 2000; 47: 404-409; the entirety of whichare incorporated herein by reference.

Induction of response or remission in Crohn's disease patients may bedetermined in accordance with one or more standard disease indices.Typical indices include the Crohn's Disease Activity Index (CDAI). TheCDAI is discussed in Love, “Pharmacotherapy for Moderate to SevereInflammatory Bowel Disease: Evolving Strategies”, Am J Manag Care. 2016;22:S39-S50; Peyrin-Biroulet et al “Defining disease severity ininflammatory bowel diseases: current and future directions” ClinGastroenterol Hepatol. 2015; pii: S1542-3565(15)00787-00789. doi:10.1016/j.cgh.2015.06.001; and Ungar et al “Advances in the developmentof new biologics in inflammatory bowel disease”, Annals ofGastroenterology (2016) 29, 243-248. Alternative indices for assessingCrohn's disease patients include the Harvey-Bradshaw index and theInflammatory Bowel Disease Questionnaire.

CDAI is a composite score taking into account a large number of symptomsassociated with Crohn's disease, including number of liquid or softstools; abdominal pain; general well being; presence of complications(the presence of joint pains (arthralgia) or frank arthritis;inflammation of the iris or uveitis; presence of erythema nodosum,pyoderma gangrenosum, or aphthous ulcers; anal fissures, fistulae orabscesses; other fistulae; fever during the previous week); use oflomotil or opiates for diarrhea; presence of an abdominal mass;hematocrit value; and percentage deviation from standard weight.Clinical remission according to the CDAI is typically indicated by ascore of <150.

The subject treated in accordance with the present invention istypically refractory or responds insufficiently or is intolerant toanti-inflammatory therapy and/or demonstrates or has previouslydemonstrated an inadequate response, loss of response, or intolerance toat least one immunomodulator, TNF-α inhibitor or anti-integrin. Thus,typically, the subject has previously received or is currently receivinganti-inflammatory therapy, preferably anti-inflammatory therapy for UCand/or immunomodulatory, TNF-α inhibitor or anti-integrin therapy,preferably such therapy for UC. Anti-inflammatory therapies for UC arediscussed herein and typically include GCS, sulfasalazine and 5-ASA.

Immunomodulators, TNF-α inhibitors and anti-integrins are discussedherein and typically include azathioprine, 6-mercaptopurine andbiologicals including the TNF-α inhibitors infliximab and biosimilarsand derivatives thereof, golimumab and biosimilars and derivativesthereof, adalimumab and biosimilars and derivatives thereof andanti-integrins vedolizumab and biosimilars and derivatives thereof.

A refractory disease or disease that responds insufficiently to therapyis typically a disease where signs and symptoms of active diseasepersist despite a history of at least one course of therapy,anti-inflammatory therapy in the context of the present invention.Typically in the context of treatment of UC, signs and symptoms ofactive disease persist despite a history of two or more courses ofanti-inflammatory therapy. A typical course of treatment withanti-inflammatory therapy for UC would be well understood by a personskilled in the art, and would typically involve a sufficient number ofdoses at sufficient dosage to induce remission in a typical patient.

Intolerance to therapy, anti-inflammatory therapy in the context of thepresent invention, means that the therapy has caused side effects in thesubject that are not tolerated, e.g. that typically lead todiscontinuation of therapy.

Typically, the subject has previously received or is currently receivingAminosalicylic acid (5-ASA), preferably 5-ASA therapy for UC.

Typically, the subject has previously received or is currently receivingoral Glucocorticosteroids (GCS), preferably oral GCS therapy for UC.

Typically, the subject who is refractory or responds insufficiently oris intolerant to anti-inflammatory therapy shows or has previously shownan inadequate response to, or loss of response to (i.e. is refractoryto) or intolerance of rectal, oral, and/or parenteral GCS treatment(including no GCS treatment due to earlier side effect).

Typically, the subject who is refractory or responds insufficiently oris intolerant to anti-inflammatory therapy has a history of or currentstatus of an inadequate response (e.g. steroid refractory) to, ORsteroid dependency, OR loss of response to, OR intolerance of GCStreatment. The steroids/GCS will typically have been received by thesubject in the course of treating ulcerative colitis.

Steroid-refractory typically refers to a subject lacking a meaningfulclinical response, i.e. showing signs and symptoms of persistentlyactive ulcerative colitis, despite a history of at least one course ofsteroid treatment, for instance an induction regimen that included adose equivalent to prednisone 40-60 mg daily over a period of 30 daysfor oral administration or over a period of 7 to 10 days for intravenous(IV) administration.

Steroid dependence typically refers to a patient who is either unable toreduce steroids below the equivalent of prednisolone 10 mg/d within 3months of starting steroids, without recurrent active ulcerativecolitis, or who has a relapse within 3 months of stopping steroids.

Intolerance of GCS treatment typically means the subject has experiencedside effects not tolerated by the subject following GCS treatment, suchas but not limited to Cushing's syndrome, osteopenia/osteoporosis,hyperglycemia, insomnia, or infection.

An inadequate response, or loss of response to an immunomodulatortypically means signs and symptoms of active ulcerative colitis persistdespite previous treatment with at least one immunomodulator, forinstance one 8 Week regimen of oral azathioprine (≥1.5 mg/kg) or6-mercaptopurine (≥0.75 mg/kg).

Intolerance to an immunomodulator typically means the subject hasexperienced nausea/vomiting, abdominal pain, pancreatitis, liverfunction test (LFT) abnormalities, lymphopenia, ThiopurineMethyltransferase (TPMT) genetic mutation, or infection or other sideeffects after receiving an immunomodulator.

An inadequate response, or loss of response to a TNF-α inhibitor meanssigns and symptoms of active ulcerative colitis persist despite previoustreatment with at least one TNF-α inhibitor, such as 4-Week inductionregimen (or doses as recommended according to the current labels) ofinfliximab (5 mg/kg (IV), 2 doses at least 2 weeks apart) or abiosimilar or derivative thereof; golimumab (200/100 mg (SC), 2 doses atleast 2 weeks apart) or a biosimilar or derivative thereof; oradalimumab (160/80 mg (SC), 2 doses at least 2 weeks apart) or abiosimilar or derivative thereof or recurrence of symptoms duringmaintenance dosing following prior clinical benefit.

Intolerance to a TNF-α inhibitor means an infusion-related reaction,demyelination, congestive heart failure, infection or other side effectsfollowing receipt of a TNF-α inhibitor.

An inadequate response, or loss of response to an anti-integrin meanssigns and symptoms of active ulcerative colitis persist despite previoustreatment with an anti-integrin, for instance at least 10 weeks regimenof vedolizumab 300 mg (IV) or a biosimilar or derivative thereof, or asrecommended in the current label, or recurrence of symptoms duringmaintenance dosing following prior clinical benefit.

Typically, the subject has been diagnosed with left sided ulcerativecolitis, i.e. distal colitis, including proctosigmoiditis.

Typically, said subject is elective for colectomy.

As used herein, the term “colectomy” refers to surgical resection of anyextent of the large intestine (colon). Herein, colectomy includes, butis not limited to, right hemicolectomy, left hemicolectomy, extendedhemicolectomy, transverse colectomy, sigmoidectomy, proctosigmoidectomy,Hartmann operation, “double-barrel” or Mikulicz colostomy, totalcolectomy (also known as Lane's Operation), total procto-colectomy andsubtotal colectomy. As used herein, the phrase “elective for colectomy”refers to a subject who may choose to undergo the procedure ofnon-emergency colectomy based on physician and surgeon assessment.Subjects elective for colectomy may be, but are not limited to, subjectsrefractory to available therapy (for ulcerative colitis) or intolerantof available therapy (for ulcerative colitis). This differs fromemergency colectomy, which is an acute intervention for subjects withacute illnesses or injuries and who require immediate medical attention.The phrase also includes subjects that are elected for colectomy.

As used herein, the term “oligonucleotide” refers to a polynucleosideformed from a plurality of linked individual nucleoside units. Sucholigonucleotides can be obtained from existing nucleic acid sources,including genomic DNA or cDNA, plasmids, vectors, or bacterial DNA, butare preferably produced by synthetic methods. The nucleoside residuescan be coupled to each other by any of the numerous knowninternucleoside linkages. Such internucleoside linkages include, withoutlimitation, the natural internucleoside phosphodiester bond or indeedmodified internucleosides such as, but not limited to, phosphorothioate,phosphorodithioate, alkylphosphonate, alkylphosphonothioate,phosphotriester, phosphoramidate, siloxane, carbonate, carboalkoxy,acetamidate, carbamate, morpholino, borano, thioether, bridgedphosphoramidate, bridged methylene phosphonate, bridgedphosphorothioate, and sulfone internucleoside linkages. The term“oligonucleotide” also encompasses polynucleosides having one or morestereospecific internucleoside linkages (e. g., (Rp)- or(Sp)-phosphorothioate, alkylphosphonate, or phosphotriester linkages).As used herein, the terms “oligonucleotide” and “dinucleotide” areexpressly intended to include polynucleosides and dinucleosides havingany such internucleoside linkage, whether or not the linkage comprises aphosphate group. In certain preferred embodiments, these internucleosidelinkages may be phosphodiester, phosphorothioate, or phosphorodithioatelinkages, or combinations thereof.

The term “oligonucleotide” also encompasses polynucleosides havingadditional substituents including, without limitation, protein groups,lipophilic groups, intercalating agents, diamines, folic acid,cholesterol and adamantane. The term “oligonucleotide” also encompassesany other nucleobase containing polymer, including, without limitation,peptide nucleic acids (PNA), peptide nucleic acids with phosphate groups(PHONA), locked nucleic acids (LNA), morpholine-backboneoligonucleotides, and oligonucleotides having backbone sections withalkyl linkers or amino linkers. The alkyl linker may be branched orunbranched, substituted or unsubstituted, and chirally pure or a racemicmixture.

The oligonucleotides of the invention can include naturally occurringnucleosides, modified nucleosides, or mixtures thereof. As used herein,the term “modified nucleoside” is a nucleoside that includes a modifiedheterocyclic base, a modified sugar moiety, or a combination thereof. Insome embodiments, the modified nucleoside is a non-natural pyrimidine orpurine nucleoside, as herein described. In some embodiments, themodified nucleoside is a 2′-substituted ribonucleoside, anarabinonucleoside or a 2′-deoxy-2′-substituted-arabinoside.

As used herein, the term “a hybrid oligonucleotide” is anoligonucleotide having more than one type of nucleoside.

Herein, the term “oligonucleotide” includes hybrid and chimericoligonucleotides. A “chimeric oligonucleotide” is an oligonucleotidehaving more than one type of internucleoside linkage within its sequencestructure. One preferred example of such a chimeric oligonucleotide is achimeric oligonucleotide comprising a phosphorothioate, phosphodiesteror phosphorodithioate region and non-ionic linkages such asalkylphosphonate or alkylphosphonothioate linkages (U.S. Pat. Nos.5,635,377 and 5,366,878).

Herein, the term “oligonucleotide” also includes circularized variantsand circular oligonucleotides.

Preferably, the oligonucleotide comprises at least one naturallyoccurring phosphodiester, or one modified phosphorothioate, orphosphorodithioate internucleoside linkage, however preferred linkagesor indeed backbone modifications including, without limitation,methylphosphonates, methylphosphonothioates, phosphotriesters,phosphothiotriesters, phosphorothioates, phosphorodithioates, triesterprodrugs, sulfones, sulfonamides, sulfamates, formacetal, 2′ OMe(OxyMethyl group at 2′position), N-methylhydroxylamine, carbonate,carbamate, morpholino, boranophosphonate, phosphoramidates, especiallyprimary amino-phosphoramidates, N3 phosphoramidates and N5phosphoramidates, and stereospecific linkages (e. g., (Rp)- or(Sp)-phosphorothioate, alkylphosphonate, or phosphotriester linkages)are also envisaged.

The sugar moiety of the nucleoside can be a non-naturally occurringsugar moiety. Herein, a “naturally occurring sugar moiety” is a sugarmoiety that occurs naturally as part of a nucleic acid, e. g., riboseand 2′-deoxyribose, and a “non-naturally occurring sugar moiety” is anysugar that does not occur naturally as part of a nucleic acid, but whichcan be used in the backbone for an oligonucleotide, for example but notlimited to hexose. Arabinose and arabinose derivatives are examples ofpreferred sugar moieties.

Modified or substituted oligonucleotides are often preferred over nativeforms because of desirable properties such as, for example, enhancedcellular uptake, enhanced affinity for nucleic acid target and increasedstability in the presence of nucleases. An oligonucleotide is usuallycomprised of more than ten (10) and up to one hundred (100) or moredeoxyribonucleotides or ribonucelotides, although preferably betweenabout eight (8) and about forty (40), most preferably between abouteight (8) and about twenty (20). The exact size will depend on manyfactors, which in turn depends on the ultimate function or use of theoligonucleotide. The oligonucleotide may be generated in any manner,including chemical synthesis, DNA replication, reverse transcription, ora combination thereof.

The oligonucleotide for use in the present invention comprises thesequence 5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2). Typically, at leastone CG dinucleotide is unmethylated.

Typically, at least one nucleotide in said oligonucleotide has abackbone modification. Typically, at least one nucleotide in saidoligonucleotide has a phosphate backbone modification. The backbonemodification is typically a phosphorothioate or a phosphorodithioatemodification.

Phosphorothioate linkages can be illustrated with asterisks (*) in asequence, e.g. in the sequence:

5′-G*G*A*ACAGTTCGTCCAT*G*G*C-3′ (SEQ ID NO:1), wherein the CGdinucleotide is unmethylated.

Preferably, said oligonucleotide has the sequence

5′-G*G*A*ACAGTTCGTCCAT*G*G*C-3′ (SEQ ID NO:1), wherein the CGdinucleotide is unmethylated. Thus, preferably said oligonucleotide iscobitolimod.

The present invention therefore preferably provides cobitolimod for usein the treatment of active ulcerative colitis as defined herein in ahuman subject as defined herein, wherein individual doses of an amountas defined herein of cobitolimod are administered to the subject on atleast four separate occasions, wherein the separate occasions are each aweek apart.

The present invention also provides cobitolimod for use in the treatmentof active ulcerative colitis as defined herein in a human subject asdefined herein, wherein individual doses of an amount as defined hereinof cobitolimod are administered to the subject every week until thepatient is in remission, for instance as defined herein.

In the therapies of the present invention, individual doses of from 100mg to 350 mg, typically 100 mg to 150 mg, of said oligonucleotide,preferably cobitolimod, are administered. Typically, the same dosage ofoligonucleotide is administered in each individual dose/administration,but different dosages may also be used.

Usually, individual doses of greater than 100 mg up to 350 mg, typicallygreater than 100 mg up to 150 mg, of said oligonucleotide, preferablycobitolimod, are administered.

Typically, from 101 mg to 150 mg of said oligonucleotide, preferablycobitolimod, are administered in each dose/administration, preferablyfrom 105 mg to 145 mg, more preferably from 110 to 140, still morepreferably from 115 to 135, yet more preferably from 120 to 130, evenmore preferably from 121 to 129, even more preferably from 122 to 128,even more preferably from 123 to 127, even more preferably from 124 to126 mg.

Preferably, about 125 mg of said oligonucleotide, preferablycobitolimod, is administered. Thus, about 125 mg of saidoligonucleotide, preferably cobitolimod, is administered every week.

In the context of dosage of an active agent, “about” as used hereinmeans+/−10%, typically +/−5%, preferably +/−1%.

More preferably, 125 mg of said oligonucleotide, preferably cobitolimod,is administered.

Alternatively, from 175 mg to 325 mg of said oligonucleotide, preferablycobitolimod, are administered in each dose/administration, preferablyfrom 200 mg to 300 mg, more preferably from 210 to 290, still morepreferably from 220 to 280, yet more preferably from 230 to 270, evenmore preferably from 240 to 260, even more preferably from 245 to 255,even more preferably from 249 to 251 mg.

Preferably, about 250 mg of said oligonucleotide, preferablycobitolimod, is administered. Thus, about 250 mg of saidoligonucleotide, preferably cobitolimod, is administered on each of theat least two occasions.

More preferably, 250 mg of said oligonucleotide, preferably cobitolimod,is administered.

In the therapies of the present invention, individual doses (of anamount as specified herein) of said oligonucleotide are administered tothe patient on at least four separate occasions, wherein the separateoccasions are each a week apart. This means that the patient does notreceive any additional oligonucleotide between the specifieddoses/administrations a week apart. In the week long window betweenspecified doses/administrations a week apart, the patient does notreceive an oligonucleotide as defined herein, but may receive one ormore additional therapeutic agents for the treatment of ulcerativecolitis.

The at least four separate occasions are consecutive. Thus, each of theat least four doses follows the previous dose (spaced apart by a week).The present invention does not extend to, for example, giving a firstdose, waiting a week, giving a second dose, waiting several months,giving a third dose, waiting a week, and giving a fourth dose.

Each of the at least four separate occasions is a week after theprevious occasion. Thus, four separate occasions each a week apart willinvolve a first administration on day zero, a second administration aweek after the first administration, a third administration a week afterthe second administration, and a fourth administration a week after thethird administration.

Typically, doses (of an amount as specified herein) of saidoligonucleotide are administered to the patient on, for instance, 4, 5,6, 7, 8, 9, or 10 separate occasions, each occasion being a week afterthe previous occasions. Typically, doses of said oligonucleotide areadministered to the patient until that patient is in remission, asdefined above. In some embodiments, individual doses are administered tothe subject on only four separate occasions, the separate occasions eachbeing a week apart.

It should be understood that reference to administration on at leastfour separate occasions, where the separate occasions are each a weekapart, refers to a single treatment regime for inducing remission. Thus,following a course of treatment in accordance with the presentinvention, further treatment with the oligonucleotide is not ruled outin the future, e.g. following relapse to an active disease state afterremission.

In the context of a patient receiving only four doses, a first dosewould be delivered at day zero, and a second dose would be delivered aweek after that, a third dose would be delivered a week after that (twoweeks after day zero), and a fourth dose would be delivered a week afterthat (three weeks after day zero).

As used herein, the term “a week apart” means in certain embodimentsadministration of the doses exactly 7 days apart, i.e. one dose isadministered on day zero and a further dose is administered on dayseven. However, it will be appreciated that minor variations from thisare still within the scope of the present invention. Such minorvariations may be unavoidable due to e.g. illness of the patient orunavailability of the drug. Thus, as used herein “a week apart” meansadministration 3-13 days, typically 4-11 days, alternatively 5-9 days,more preferably 6-8 days apart.

Thus, in certain embodiments the present invention provides anoligonucleotide, as defined herein, for use in the treatment ofulcerative colitis, as defined herein, in a human subject, as definedherein, wherein individual doses of an amount as defined herein of saidoligonucleotide are administered to the patient on at least four, forinstance four, separate occasions, wherein the separate occasions areeach 3-13 days, typically 4-11 days, alternatively 5-9 days, preferably6-8 days apart.

The drugs for use in the present invention may be administered asmonotherapy treatment for the indication or with other drug(s) asadjunct therapy for the indication, as described in more detail below.In the case of adjunct (or “add-on”) therapy, the drugs for use in thepresent invention may be administered simultaneously, separately orsequentially with the other drug(s), for example in fixed dosecombination or in separate doses.

As used herein, the term “add-on” refers to administering of saidoligonucleotide in addition to a current therapy or drug regime, withoutdiscontinuing the current therapy or drug regime.

Thus, the oligonucleotide may be administered as a monotherapy, or incombination with one or more additional therapeutic agents for thetreatment of ulcerative colitis. Typically, the oligonucleotide may beadministered as a monotherapy, or in combination with one or moreadditional therapeutic agents for the treatment of ulcerative colitischosen from immunomodulatory drugs, anti-TNF therapy drugs or othersuitable drugs for treating ulcerative colitis.

Examples of such drugs suitable for use in combination with saidoligonucleotide include, but are not limited to GCS or derivatives;prednisolone, Decortin, anti-TNF or derivative; infliximab andbiosimilars and derivatives thereof, adalimumab and biosimilars andderivatives thereof, golimumab and biosimilars and derivatives thereof,anti-integrin or derivatives; vedolizumab and biosimilars andderivatives thereof, natural IFN-β, thiopurine or derivatives;azathioprine, 6-mercaptopurine, 5-ASA, sulphasalazine, methotrexate,cylclosporine, and equivalents thereof.

Typically, the subject receiving said oligonucleotide also receives oneor more other drugs chosen from GCS, Decortin, 5-ASA, azathioprine,6-mercaptopurine, sulphasalazine, methotrexate, prednisolone andequivalents thereof or derivatives.

Preferably, the subject receiving said oligonucleotide also receives oneor more other drugs chosen from GCS, 5-ASA, azathioprine,6-mercaptopurine, sulphasalazine and methotrexate.

More preferably, the subject receiving said oligonucleotide alsoreceives one or more other drugs chosen from oral GCS, oral 5-ASA,azathioprine, 6-mercaptopurine, and oral methotrexate.

In some embodiments, the subject receiving said oligonucleotide alsoreceives one or more steroid drugs, for example corticosteroids andglucocorticosteroids.

For purposes of the invention, the terms “in combination with” and“add-on” mean in the course of treating the same disease in the samepatient, and include administering the oligonucleotide and one or moreadditional therapeutic agents in any order, including simultaneousadministration, as well as temporally spaced order of up to severalmonths apart.

Typically, said oligonucleotide is administered topically, such astopically to the mucous membrane.

Typically, said oligonucleotide is administered intracolonically.Intracolonical administration is typically effected rectally.Intracolonical administration is typically effected using an enema orcatheter. Intracolonical administration may involve administration by arectal enema. Intracolonical administration may be topical, for exampleperformed during colonoscopy with the aid of a spraying catheter, orother suitable medical equipment, inserted though the colonoscopiesbiopsy channel. The said oligonucleotide may be delivered to the upperportion of the descending colon or to the transverse region of thecolon; however other regions are also possible when suited. Topicaladministration to other parts of the gastrointestinal tract is alsopossible. Yet in another embodiment of this aspect, the saidoligonucleotide can be administered by any appropriate administrationroute, such as, but not limited to, inhalation, intranasal, parenteral,oral, intradermal, subcutaneous, vaginal and rectal administration.Further, in certain embodiments, systemic administration of saidoligonucleotide may be used.

The oligonucleotide may be administered in the form of a pharmaceuticalcomposition comprising the oligonucleotide as defined herein togetherwith one or more pharmaceutically acceptable carriers. As used herein,the term “carrier” encompasses any excipient, diluent, filler, salt,buffer, water, stabilizer, solubilizer, lipid, or other material wellknown in the art for use in pharmaceutical formulations. It will beunderstood that the characteristics of the carrier will depend on theroute of administration for a particular application.

As used herein, the term “pharmaceutically acceptable” refers to amaterial that does not interfere with the effectiveness of theimmunomodulatory oligonucleotide and is compatible with a biologicalsystem such as a cell, cell culture, tissue, organ, or organism.Preferably, the biological system is a living organism, such as avertebrate.

Typically, the composition is a solution of the oligonucleotide in aliquid carrier.

Typically, the carrier is water, preferably sterile water. Thus,typically the composition comprises the oligonucleotide as definedherein and water.

Preferably, the carrier is water and the oligonucleotide (in the form ofa composition) is administered intracolonically, for instance as arectal enema.

The oligonucleotide has been found to be advantageously stable in water,and it is therefore possible to administer the oligonucleotide as acomposition consisting essentially of the oligonucleotide as definedherein and water. The composition may consist of the oligonucleotide asdefined herein and water.

A composition consisting essentially of components refers to acomposition comprising the components of which it consists essentiallyas well as other components, provided that the other components do notmaterially affect the essential characteristics of the composition.Typically, a composition consisting essentially of certain componentswill comprise greater than or equal to 95 wt % (relative to the totalweight of the composition) of those components or greater than or equalto 99 wt % (relative to the total weight of the composition) of thosecomponents.

Thus, a composition consisting essentially of the oligonucleotide asdefined herein and water comprises greater than or equal to 95 wt % ofoligonucleotide and water (relative to the total weight of thecomposition) or greater than or equal to 99 wt % of oligonucleotide andwater (relative to the total weight of the composition).

The concentration of an oligonucleotide in a pharmaceutical compositionwill vary depending on several factors, including the dosage of theoligonucleotide to be administered. Typical concentrations ofoligonucleotides in compositions that are solutions are 1 mg/ml to 10mg/ml, preferably 2 to 5 mg/ml, in some cases 5 to 10 mg/ml preferably2.4 mg/ml to 2.6 mg/ml, more preferably about 2.5 mg/ml. Alternatively,concentrations of oligonucleotides in compositions that are solutionsare 1 mg/ml to 20 mg/ml, preferably 4 to 10 mg/ml, in some cases 10 to20 mg/ml, preferably 4.8 mg/ml to 5.2 mg/ml, more preferably about 5.0mg/ml.

Preferably, the present invention provides cobitolimod for use in thetreatment of ulcerative colitis, as defined herein, in a human subject,as defined herein, wherein individual doses of about 125 mg ofcobitolimod are administered to the patient on only four separateoccasions, the separate occasions each being a week apart.

Alternatively, the present invention provides cobitolimod for use in thetreatment of ulcerative colitis, as defined herein, in a human subject,as defined herein, wherein individual doses of about 125 mg ofcobitolimod are administered to the patient on four or more separateoccasions, the separate occasions each being a week apart, until thesubject is in remission, typically remission as determined by an indexas defined herein.

More preferably the present invention provides cobitolimod for use inthe treatment of active ulcerative colitis, as defined herein, in ahuman subject, as defined herein, wherein individual doses of about 125mg of cobitolimod are administered to the patient on only four separateoccasions, the separate occasions each being a week apart, whereincobitolimod is administered in the form of a pharmaceutical compositioncomprising cobitolimod and water.

More preferably the present invention provides cobitolimod for use inthe treatment of active ulcerative colitis, as defined herein, in ahuman subject, as defined herein, wherein individual doses of about 125mg of cobitolimod are administered to the patient on only four separateoccasions, the separate occasions each being a week apart, whereincobitolimod is administered intracolonically or rectally.

More preferably the present invention provides cobitolimod for use inthe treatment of active ulcerative colitis, as defined herein, in ahuman subject, as defined herein, wherein individual doses of about 125mg of cobitolimod are administered to the patient on only four separateoccasions, the separate occasions each being a week apart, whereincobitolimod is administered intracolonically or rectally in the form ofa pharmaceutical composition comprising cobitolimod and water.

Even more preferably the present invention provides cobitolimod for usein the treatment of chronic active ulcerative colitis, as definedherein, in a human subject, as defined herein, wherein individual dosesof about 125 mg of cobitolimod are administered to the patient on onlyfour separate occasions, the separate occasions each being a week apart,wherein cobitolimod is administered intracolonically or rectally in theform of a pharmaceutical composition comprising cobitolimod and water.

The present invention also provides a pharmaceutical compositioncomprising an oligonucleotide as defined herein, together with one ormore pharmaceutically acceptable carriers, for use in the treatment ofan inflammatory bowel disease as defined herein in a human subject asdefined herein, wherein individual administrations of said compositionare administered to the subject on at least four separate occasions,wherein the separate occasions are each a week apart, and wherein eachadministration of the composition delivers an amount of theoligonucleotide as defined herein.

Preferred features of the oligonucleotide for use as defined above arealso preferred features of the composition for use.

The present invention also provides use of an oligonucleotide as definedherein, or a pharmaceutical composition as defined herein, in themanufacture of a medicament for use in treating an inflammatory boweldisease as defined herein, in a human subject as defined herein, whereinindividual administrations of said oligonucleotide or composition areadministered to the patient on at least four separate occasions, whereinthe separate occasions are each a week apart, and wherein eachadministration of the oligonucleotide or composition delivers an amountof the oligonucleotide as defined herein.

Preferred features of the oligonucleotide for use as defined above arealso preferred features of the use of the oligonucleotide orcomposition.

The present invention also provides a method of treating an inflammatorybowel disease as defined herein, in a human subject as defined herein,comprising administering to said subject an oligonucleotide as definedherein or a composition as defined herein, wherein individualadministrations of said oligonucleotide or composition are administeredto the patient on at least four separate occasions, wherein the separateoccasions are each a week apart, and wherein each administration of theoligonucleotide or composition delivers an amount of the oligonucleotideas defined herein.

The present invention also provides a method of treating an inflammatorybowel disease as defined herein, in a human subject as defined herein,which method comprises:

-   -   (a) selecting a patient as defined herein; and    -   (b) administering to said patient an oligonucleotide as defined        herein or a composition as defined herein, wherein individual        administrations of said oligonucleotide or composition are        administered to the patient on at least four separate occasions,        wherein the separate occasions are each a week apart, and        wherein each administration of the oligonucleotide or        composition delivers an amount of the oligonucleotide as defined        herein.

Preferred features of the oligonucleotide for use as defined above arealso preferred features of the claimed method.

The following non-limiting Examples illustrate the invention.

EXAMPLES Example 1—Clinical Trial Study

A randomised double-blind, placebo controlled, trial assesses theefficacy and safety of topical cobitolimod in moderate to severe activeulcerative colitis patients in accordance with established methods.

Methods: Men and women are selected for trial according to standardinclusion criteria in the field including the following:

-   -   1. Male or female≥18 years of age    -   2. Established diagnosis of UC, with minimum time from diagnosis        of ≥3 months    -   3. Moderately to severely active left sided UC (disease should        extend 15 cm or more above the anal verge and not beyond the        splenic flexure) determined by a Modified Mayo score (excluding        the friability at grade 1 for the endoscopic sub score) of 6 to        12 with an endoscopic sub score≥2 assessed by central reading of        endoscopy performed at screening visit 1b (Day −7 to        −10—screening visit), and no other individual sub score<1    -   4. Current oral 5-ASA/SP use or a history of oral 5-ASA/SP use    -   5. Current GCS use or history of GCS dependency, refractory, or        intolerance, including no GCS treatment due to earlier        side-effects (only one of the GCS criteria have to be fulfilled,        see definition in European Crohn's and Colitis organisation        (ECCO) guidelines)    -   6. Demonstrated an inadequate response, loss of response, or        intolerance to at least one of the following agents:        -   Immunomodulators, e.g. cyclosporine, methotrexate, AZA/6-MP,            tacrolimus            -   For example, signs and symptoms of persistently active                disease despite previous treatment with at least one 8                week regimen of oral AZA (≥1.5 mg/kg) or 6-MP (≥0.75                mg/kg) or lower doses prompted by intolerance or                thiopurine methyltransferase (TPMT) deficiency or            -   For example, previous intolerance (including, but not                limited to, nausea/vomiting, abdominal pain,                pancreatitis, liver function test (LFT) abnormalities,                lymphopenia, TPMT genetic mutation, infection) to at                least one immunomodulator        -   TNF-α inhibitors and/or anti-integrins:            -   Signs and symptoms of persistently active disease                despite previous treatment with at least one induction                regimen with 2 doses at least 2 weeks apart (or doses as                recommended according to the current labels) of for                e.g.:                -   Infliximab 5 mg/kg (intravenous (IV)) or                -   Golimumab 200/100 mg (subcutaneous (SC)) or                -   Adalimumab 160/80 mg (SC) or                -   Vedolizumab 300 mg (IV) or            -   History of intolerance (including but not limited to                infusion-related reaction, demyelination, congestive                heart failure, infection)

Recurrence of symptoms during maintenance dosing with any of the abovemedications following prior clinical benefit, (secondary failure)[discontinuation despite clinical benefit does not qualify]

-   -   7. Allowed to receive a therapeutic dose of following UC drugs        during the study:        -   a) Oral GCS therapy (≤20 mg prednisone or equivalent/daily)            providing that the dose has been stable for 2 weeks prior to            visit 1a (Day −14)        -   b) Oral MMX Budesonide therapy (9 mg/daily) initiated at            least 8 weeks before visit 1a        -   c) Oral 5-ASA/SP compounds, providing that the dose has been            stable for 2 weeks prior to visit 1a and initiated at least            8 weeks before visit 1a        -   d) AZA/6-MP providing that the dose has been stable for 8            weeks prior to visit 1b and been initiated at least 3 months            before visit 1a    -   8. Ability to understand the treatment, willingness to comply        with all study requirements and ability to provide informed        consent

Patients may be excluded from trial in accordance with known exclusioncriteria in the field including the following:

-   -   1. Suspicion of differential diagnosis such as; Crohn's        enterocolitis, ischaemic colitis, radiation colitis,        indeterminate colitis, infectious colitis, diverticular disease,        associated colitis, microscopic colitis, massive pseudopolyposis        or non-passable stenosis    -   2. Acute fulminant UC and/or signs of systemic toxicity    -   3. UC limited to the rectum (disease which extend <15 cm above        the anal verge)    -   4. History of malignancy, except for:        -   Treated (cured) basal cell or squamous cell in situ            carcinoma        -   Treated (cured) cervical intraepithelial neoplasia or            carcinoma in situ of the cervix with no evidence of            recurrence within the previous 5 years prior to the            screening visit 1a    -   5. History or presence of any clinically significant disorder        that, in opinion of the investigator, could impact on patient's        possibility to adhere to the protocol and protocol procedures or        would confound the study result or compromise patient safety    -   6. Concomitant treatment with cyclosporine, methotrexate,        tacrolimus, TNF-α inhibitors, anti-integrins or similar        immunosuppressants and immunomodulators at enrolment. Any prior        treatment with such drugs must have been discontinued at least 8        weeks prior to visit 1a or have non-measurable serum        concentration levels    -   7. Treatment with rectal GCS, 5-ASA/SP or tacrolimus within 2        Weeks before visit 1b    -   8. Long term treatment with antibiotics or non-steroidal        anti-inflammatory drugs (NSAIDs) within two weeks prior to visit        1a (one short treatment regime for antibiotics and occasional        use of NSAIDS are allowed)    -   9. Serious active infection    -   10. Gastrointestinal infections including positive Clostridium        difficile stool assay    -   11. Currently receiving parenteral nutrition or blood        transfusions    -   12. Females who are lactating or have a positive serum pregnancy        test during the screening period    -   13. Women of childbearing potential not using reliable        contraceptive methods (reliable methods are barrier protection,        hormonal contraception, intra-uterine device or abstinence)        throughout the duration of the study    -   14. Concurrent participation in another clinical study with        investigational therapy or previous use of investigational        therapy within 5 half-lives and within at least 30 days after        last treatment of the experimental product prior to enrolment    -   15. Previous exposure to cobitolimod

Patients selected for trial are randomised to treatment sequencescomprising cobitolimod at effective dosage (including a group receivingfour administrations of 125 mg cobitolimod each a week apart (Week zero,week 1, week 2, week 3)) and placebo administered rectally by rectalenema.

Trial endpoints/assessed clinical criteria are as follows:

-   -   Proportion of patients with induction of clinical remission,        symptomatic remission, endoscopic remission or (complete)        histological remission at Week 4 or 6    -   Proportion of patients with absence of rectal bleeding at Week 4        or 6    -   Proportion of patients with normal or enhanced stool frequency        at Week 4 or 6    -   Proportion of patients with induction of durable symptomatic        remission at Week 6 and Week 10    -   Proportion of patients in clinical response at Week 6    -   Proportion of patients with histological response at Week 6    -   Proportion of patients with reduced defecation urgency score    -   Mean change in faecal calprotectin at Week 1, 2, 3, and 6        compared to Week 0    -   Mean change in steroid dosage for patients in remission at Week        6 to Week 10    -   Mean change in each of the inflammatory bowel disease        questionnaire (IBDQ) sub domains at Week 6 compared to Week 0    -   Proportion of patients with endoscopic and histological        remission at Week 6

Conclusion: Treatment with four doses of 125 mg cobitolimod each a weekapart in patients suffering from moderate to severe ulcerative colitisleads to improved clinical effects indicating usefulness of cobitolimodin treating ulcerative colitis.

Example 2—Dextran Sulfate Sodium (DSS) Induced Colitis Mouse Model

Materials and Methods

Mice:

Balb/c mice were obtained from Charles River Laboratories, ResearchModels and Services (Sulzfeld, Germany). Eight week old female Balb/cmice were used for the experiments and were kept in individuallyventilated cages in compliance to the Animal Welfare Act. Water and foodwere available ad libitum.

DSS Induced Colitis:

3% (w/v) Dextran sulfate sodium (DSS) (MP Biomedicals, Illkirch, France)was administrated for 10 days to the drinking water of 8 week old femaleBalb/c mice. An additional control group of three mice which werecompletely untreated was also part of the experimental set up. Fooduptake and bodyweight were monitored on days 0, 2, 4, 6, 7, 8, and 10.

Rectal Administration of Cobitolimod:

40 μg, 84 μg, or 1560 μg cobitolimod per mouse was rectally administeredtwice (on days 4 and 8). 500 μg cobitolimod per mouse was rectallyadministered four times (on days 4, 5, 6 and 8). The respectiveconcentration of cobitolimod was diluted with sterile water and 100 μlper mouse was used for rectal administration. A dose of 500 μg in miceis approximately equivalent to a 125 mg dose in a human (see “Guidancefor Industry—Estimating the Maximum Safe Starting Dose in InitialClinical Trials for Therapeutics in Adult Health Volunteers”, USDepartment of Health and Human Services Food and Drug AdministrationCenter for Drug Evaluation and Research, July 2005). The resultsobserved in this mouse model could be considered predictive of theeffects observed in humans administered with individual doses of from100 mg to 150 mg of cobitolimod on four separate occasions, each a weekapart. The dose of 84 μg in mice is broadly equivalent to a dose of 30mg in humans.

Sterile water without cobitolimod was additionally rectally applied to acontrol group of seven mice (placebo). Mice from different treatedgroups were randomly mixed per cage before initiation of the experimentto ensure comparable experimental conditions.

Evaluation of DSS Induced Colitis:

Loss of bodyweight was monitored on the days 0, 2, 4, 6, 7, 8 and 10.The Disease Activity Index (DAI) is the combined score of body weightloss compared to initial body weight, stool consistency, and visibleblood in feces. The maximum score per mouse is 12. The DAI was assessedon the days 0, 2, 4, 6, 7, 8 and 10. Additionally, colon inflammationwas studied in vivo using the Coloview endoscopic system consisting of aminiature endoscope (scope 1.9 mm outer diameter), a xenon light source,a triple chip camera and an air pump (all from Karl Storz, Tutzingen,Germany) to achieve regulated inflation of the mouse colon. Forendoscopy mice were anesthetized with 4% of isoflurane in 100% oxygen ata rate of 0.2-0.5 L/mins, 2% isoflurane was used for maintenance. Theendoscopic colitis grading consists of the five parameters: thickeningof the colon, change of the normal vascular pattern, presence of fibrin,mucosal granularity and stool consistency. Endoscopic grading wasperformed for each parameter (score 0-3) leading to an accumulativescore between 0-15. Endoscopic grading was analyzed on days 0, 2, 4, 6,7, 8 and 10.

Results

FIG. 1 shows the change in body weight of the mice in the varioustreatment groups over the course of the experiment. Four days afterinitiation of DSS treatment all DSS treated groups started to loseweight in a comparable way. Rectal application of cobitolimod resultedin a significant reduction in weight loss at day 6 in mice treated with84 μg cobitolimod and 500 μg cobitolimod compared to placebo treatedmice.

At day 7, weight loss was more significantly reduced in the grouptreated with 500 μg cobitolimod (**P=0.0012) compared to the grouptreated with 84 μg cobitolimod (*P=0.0122) and thereafter the weightloss in both groups continued to be significantly less than that in theplacebo treated group up until day 10 (the end of the experiment).

No significant reduction in weight loss was noted for the group treatedwith 40 μg cobitolimod compared to the placebo group. The group treatedwith 1560 μg cobitolimod showed increased weight loss compared toplacebo treated mice. At the end of the experiment on day 10, allcobitolimod treated groups show reduced weight loss compared to theplacebo treated group, apart from the group treated with 1560 μgcobitolimod which showed similar weight loss to that of the placebotreated group. The body weight of mice which were completely untreated(no DSS, no cobitolimod/placebo) did not change throughout theexperiment (FIG. 1 ).

FIG. 2 shows the change in disease activity index (DAI) of the mice inthe various treatment groups over the course of the experiment. The DAIdata also revealed that rectal application of cobitolimod amelioratesDSS induced colitis. All cobitolimod treated mice show similar changesin the DAI except for 40 μg cobitolimod treated mice. The mice grouptreated with 40 μg cobitolimod did not exhibit a significant reductionin DAI compared to the placebo control. Mice treated with 84 μg and 500μg of cobitolimod showed a reduction in DAI from day 6 until the end ofthe experiment compared to placebo treated mice with a significantreduction in DAI noted at days 8 and 10 (***P=0.0006). The mice grouptreated with 1560 μg of cobitolimod show a reduced DAI at day 7 and atday 8 and 10 the reduction was significant (**P=0.0023 and ***P=0.0006,respectively). The DAI of mice which were completely untreated (no DSS,no cobitolimod/placebo) did not change throughout the experiment (FIG. 2).

FIG. 3 shows the change in endoscopic colitis grading of the mice in thevarious treatment groups over the course of the experiment. Theendoscopic colitis grading is consistent with the results for weightloss and DAI. All mice treated with cobitolimod developed fewer signs ofDSS induced colitis compared to the placebo treated group. Theendoscopic colitis grading compared to the placebo group reduced afterthe first application of cobitolimod until the end of the experiment forall cobitolimod treated groups. The reduction was significant (**P≤0.01)from day 7 for all cobitolimod treated groups except for 40 μgcobitolimod treated group (FIG. 3 ).

Conclusion

Taken together, these results show that cobitolimod treatmentameliorated DSS-induced colitis, by significantly reduced the weightloss, disease activity index and endoscopic colitis grade of the mice.In particular, in the mice that were administered 500 μg of cobitolimodat days 4, 5, 6 and 8, significant improvements for weight loss, DAI andendoscopic colitis grading were achieved.

Example 3—Flow Cytometry Results for Dextran Sulfate Sodium (DSS)Induced Colitis Mouse Model

Materials and Methods

Mice:

Balb/c mice were obtained from Charles River Laboratories, ResearchModels and Services (Sulzfeld, Germany). Eight week old female Balb/cmice were used for the experiments and were kept in individuallyventilated cages in compliance to the Animal Welfare Act. Water and foodwere available ad libitum.

DSS Induced Colitis:

3% (w/v) Dextran sulfate sodium (DSS) (MP Biomedicals, Illkirch, France)was administrated for 10 days to the drinking water of 8 week old femaleBalb/c mice. An additional control group of three mice which werecompletely untreated was also part of the experimental set up.

Rectal Administration of Cobitolimod:

40 μg, 84 μg, 500 μg or 1560 μg cobitolimod per mouse was administeredrectally twice (on days 4 and 8). The respective concentration ofcobitolimod was diluted with sterile water and 100 μl per mouse was usedfor rectal administration. A dose of 500 μg in mice is approximatelyequivalent to a 125 mg dose in a human (human equivalent dose, HED—see“Guidance for Industry—Estimating the Maximum Safe Starting Dose inInitial Clinical Trials for Therapeutics in Adult Health Volunteers”, USDepartment of Health and Human Services Food and Drug AdministrationCenter for Drug Evaluation and Research, July 2005). The dose of 84 μgin mice is broadly equivalent to a dose of 30 mg in humans.

Sterile water without cobitolimod was additionally rectally applied to acontrol group of seven mice (placebo). Mice from different treatedgroups were randomly mixed per cage before initiation of the experimentto ensure comparable experimental conditions.

Flow Cytometry:

Mice were sacrificed via cervical dislocation on day 10 and colonspecimens were taken for flow cytometry analysis. Lamina propriamononuclear cells (LPMCs) from gut specimen were isolated using thelamina propria kit (Miltenyi Biotec, Bergisch Gladbach, Germany). Priorto intracellular staining, cells were treated with a stimulationcocktail containing PMA, Golgi-Stop and Ionomycin (eBioscience,Frankfurt, Germany) for 4 hours at 37° C. Cells were fixed andpermeabilized using a transcription factor buffer set (BD Biosciences,Heidelberg, Germany). Cells were stained for CD4 (BD Pharmingen,Franklin, USA), IL17A (Biolegend, San Diego, USA), RoryT (BD Pharmingen,Franklin, USA), and respective isotype controls. For myeloid-derivedsuppressor cells (MDSCs), isolated LPMCs were extracellularly stainedfor CD11b (Miltenyi Biotec, Bergisch Gladbach, Germany) and Gr-1 (BDPharmingen, Franklin, USA). Flow cytometry analysis was performed withFACS Calibur (BD Biosciences, Heidelberg, Germany). Cells were analyzedusing the FlowJo single cell analysis software (Version 10.1r5, TreeStarAshland, USA).

Statistical Analysis:

Statistical analysis was performed using Graph Pad Prism (Graph PadSoftware Version 6.05, La Jolla, Calif.). After testing for normaldistribution with the Shapiro Wilk normality test, significantdifferences between samples were calculated using the unpaired Student'st test or the Mann-Whitney U-rank test (*P≤0.05; **P≤0.01; ***P≤0.001).

Results

FIG. 4 shows the results of intracellular staining of LPMCs in colonsamples harvested from the mice on day 10. Classically, IBD was thoughtto be primarily mediated by Th1 cells in CD or Th2 cells in UC, but itis now known that Th17 cells and their related cytokines are crucialmediators in both conditions. Th17 cells massively infiltrate theinflamed intestine of IBD patients, where they produce IL17A and othercytokines, triggering and amplifying the inflammatory process (GálvezJ., Role of Th17 Cells in the Pathogenesis of Human IBD. ISRN Inflamm.2014 Mar. 25; 2014:928461). It has been shown that the levels ofIL17/Th17 were significantly higher in serum/colon of UC patientscompared with healthy control subjects (Gong, Y., et al., The Th17/Tregimmune balance in ulcerative colitis patients with two different chinesesyndromes: dampness-heat in large intestine and spleen and kidney yangdeficiency syndrome. Evid Based Complement Alternat Med. 2015: p.264317). Therefore, reduction of Th17 and IL17 is an important step toimprove clinical end points in IBD patients.

The colonic LPMCs were stained for the presence of Th17 cells andtranscription factor retinoic acid receptor-related orphan receptorgamma t (RORγt, the transcription factor that regulates Th17differentiation). As expected, the Th17 (RORγt⁺, IL17⁺), RORγt⁺, andIL17⁺ cell populations were increased in mice suffering from colitis(DSS treated) as compared to healthy animals (controls, no DSS). Thisincrease was significantly dampened after cobitolimod treatment comparedto water treatment. Flow cytometry analysis of LPMCs isolated from mousecolon specimens taken at the end of the experiment on day 10 revealedsignificantly reduced levels of RoryT⁺IL17⁺, RoryT⁺ and IL17⁺ T-cells incobitolimod treated mice compared to placebo treated mice. The reductionof CD4⁺IL17⁺ cells was more pronounced in the 500 μg cobitolimod treatedgroup than in the other groups (FIG. 4 ).

FIG. 5 shows flow cytometry analysis showing the percentage of Myeloidderived suppressor cells (CD11⁺Gr1⁺) present in the Lamina propriamononuclear cells (LPMCs) isolated from mouse colons on day 10.

Myeloid cells are the most abundant and heterogeneous population ofleukocytes. They are rapidly recruited from the blood to areas ofinflammation and perform a number of important biological functions.Chronic inflammatory conditions contribute to generation ofmyeloid-derived suppressor cells (MDSCs). These pathologically activatedcells are increasingly recognized as important players in cancer andIBD. The role of MDSCs in IBD is still controversial, however it hasbeen shown that MDSCs induced by intestinal inflammation conditionsmight be involved in Th17 generation and IL17 production andestablishing the pro-inflammatory environment thereby playing a role inthe pathogenesis of IBD (reviewed in Yeon-Jeong Kim., et al.,Myeloid-Derived Suppressor Cells in Inflammatory Bowel Disease. Intest.Res. 2015: 13(2): 105-111). Therefore, reduction of MDSCs can contributeto the treatment of intestinal inflammation in IBD patients.

Further analysis revealed elevated levels of Gr1⁺CD11b⁺ MDSCs in placebotreated mice compared to cobitolimod treated mice. Mice treated with 500μg cobitolimod significantly (*P≤0.05) down regulated the level ofGr1⁺CD11b⁺ MDSCs (FIG. 5 ). The reduction in Gr1⁺CD11b⁺ MDSC populationwas most pronounced for the mice administered 500 μg of cobitolimod.

CONCLUSION

These results show that cobitolimod treatment significantly reduced thepro-inflammatory IL17+ mucosal T-cells and the Gr1⁺CD11b⁺ MDSCpopulation in the colons of mice in the DSS-induced colitis model. Thesemice also showed the most promising results in the samples taken fromthe colons (reduction in IL17+ CD4+ cells and Gr1⁺CD11b⁺ MDSCpopulation). Surprisingly, the reduction in IL17+ CD4+ cells for the 500μg dose is greater than that for the 84 μg and 1560 μg doses, suggestingthat dosages between these values are most effective in modulating theimmune response in IBD. This finding also suggests that, in humans, adosage regime of from 100 mg to 150 mg of cobitolimod on at least fourseparate occasions a week apart would be better able to modulate theimmune response than other higher and lower doses, and would thereforebe particularly effective for treating IBD.

The invention claimed is:
 1. A method of treating moderate-to-severeactive ulcerative colitis in a human subject comprising administering tosaid subject an oligonucleotide comprising the sequence5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2), wherein individual doses offrom 100 mg to 350 mg of said oligonucleotide are administered to thesubject on at least four separate occasions, wherein the separateoccasions are each a week apart, wherein said subject is refractory orresponds insufficiently or is intolerant to anti-inflammatory therapyand/or wherein said subject is elective for colectomy.
 2. The methodaccording to claim 1, wherein said active ulcerative colitis is chronicactive ulcerative colitis.
 3. The method according to claim 1, whereinat least one CG dinucleotide is unmethylated, and/or wherein at leastone nucleotide in said oligonucleotide has a backbone modification. 4.The method according to claim 3, wherein said backbone modification is aphosphate backbone modification represented by a phosphorothioate or aphosphorodithioate modification.
 5. The method according to claim 1,wherein said oligonucleotide has the sequence 5′-GGAACAGTTCGTCCATGGC-3′(SEQ ID NO:2), wherein the CG dinucleotide is unmethylated.
 6. Themethod according to claim 1, wherein said oligonucleotide has thesequence 5′-G*G*A*ACAGTTCGTCCAT*G*G*C-3′ (SEQ ID NO: 1), wherein the CGdinucleotide is unmethylated, and wherein * represents aphosphorothioate linkage.
 7. The method according to claim 1, whereinindividual doses of 100 mg to 150 mg of said oligonucleotide areadministered.
 8. The method according to claim 1, wherein individualdoses of about 125 mg of said oligonucleotide are administered.
 9. Themethod according to claim 1, wherein (a) individual doses of saidoligonucleotide are administered to the subject on only four separateoccasions, wherein the separate occasions are each a week apart, or (b)individual doses of said oligonucleotide are administered to the subjecton at least four separate occasions, wherein the separate occasions areeach a week apart, until the subject is in remission.
 10. The methodaccording to claim 1, wherein the subject receives one or moreadditional therapeutic agents for the treatment of an inflammatory boweldisease.
 11. The method according to claim 1, wherein saidoligonucleotide is administered topically to mucosal membranes.
 12. Themethod according to claim 1, wherein said oligonucleotide isadministered rectally.
 13. The method according to claim 1, wherein theoligonucleotide is cobitolimod, and individual doses of about 125 mg ofcobitolimod are administered to the subject on only four separateoccasions, wherein the separate occasions are each a week apart.
 14. Amethod of treating moderate-to-severe active ulcerative colitis in ahuman subject, comprising administering to said subject a pharmaceuticalcomposition comprising an oligonucleotide comprising the sequence5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2), together with one or morepharmaceutically acceptable carriers, wherein individual administrationsof said composition are administered to the subject on at least fourseparate occasions, wherein the separate occasions are each a weekapart, and wherein each administration of the composition delivers anamount of from 100 mg to 350 mg of said oligonucleotide, wherein saidsubject is refractory or responds insufficiently or is intolerant toanti-inflammatory therapy and/or wherein said subject is elective forcolectomy.
 15. The method according to claim 14, wherein thepharmaceutically acceptable carrier is water.
 16. The method accordingto claim 14, wherein the pharmaceutically acceptable carrier is abuffer.
 17. A method of treating moderate-to-severe active ulcerativecolitis in a human subject, comprising administering to said subject apharmaceutical composition comprising an oligonucleotide comprising thesequence 5′-GGAACAGTTCGTCCATGGC-3′ (SEQ ID NO:2), wherein individualdoses of from 100 mg to 350 mg of said oligonucleotide are administeredto the subject every week until the subject is in remission, whereinsaid subject is refractory or responds insufficiently or is intolerantto anti-inflammatory therapy and/or wherein said subject is elective forcolectomy.
 18. The method according to claim 1, wherein saidoligonucleotide is cobitolimod.
 19. The method according to claim 10,wherein the subject receives one or more additional therapeutic agentsfor the treatment of ulcerative colitis.